Monday, September 24, 2018

Long-Term Use of Antidepressants Doesn’t Increase Dementia Risk, Study Finds

While the long-term use of most antidepressants does not appear to increase the risk of dementia, long-term use of the selective serotonin reuptake inhibitor (SSRI) paroxetine may, suggests a study in the Journal of the American Geriatrics Society.

Laura Heath, Ph.D., of the University of Washington and colleagues examined the health data of 3,059 older adults who were part of Kaiser Permanente Washington’s Adult Changes in Thought (ACT) study, a longitudinal study tracking brain changes prior to the onset of dementia.

The investigators used this longitudinal data to compare dementia rates in patients with cumulative antidepressant use, which was divided into four categories of medication exposure over the previous decade: none, low (1 to 90 days), medium (90 days to one year), high (1 to 3 years), and very high (3+ years). Antidepressants were also grouped into five categories: paroxetine, other SSRIs, serotonin antagonist and reuptake inhibitors (SARIs), tricyclic antidepressants, and all other antidepressants.

Heath and colleagues identified no association between antidepressant use and dementia risk for most groups of antidepressants, regardless of how much medication people took. In contrast, some patients with a history of paroxetine use (high and low use groups) were found to be at a statistically significant increased risk of dementia compared with those with no antidepressant use; patients in the medium and very high categories also showed higher risk, but it was not significant. The authors suggested these findings point to paroxetine posing a dementia risk that is not based on cumulative exposure to the medication.

The authors also found that patients with a low exposure to SARIs such as trazodone had a slightly lower risk of dementia. Some preclinical evidence has hinted that trazodone might have neuroprotective properties, but this connection needs further investigation, the authors said.

“Given the primary results and the sensitivity analyses that showed higher risk of dementia … in [paroxetine] users with depression than in nonusers with depression, who may already be at higher risk of dementia because of depression, our findings suggest that some caution may be warranted in prescribing paroxetine for depression in older adults,” the authors concluded.

For related information, see the Psychiatric News article “Long-Term SSRI Use May Slow Progression to Alzheimer’s Dementia.”

(Image: BCFC/Shutterstock)

Friday, September 21, 2018

APA Awarded CMS Funding to Develop Quality Measures

APA has received an award from the Centers for Medicare and Medicaid Services (CMS) to help develop mental health and substance use quality measures for CMS’s Quality Payment Program (QPP).

The QPP is the updated reimbursement system for CMS that was established under the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA). MACRA authorized CMS to provide incentives that encourage physicians to focus on quality, value of care, and patient health.

APA is working with the National Committee for Quality Assurance (NCQA), a nonprofit organization that is experienced at developing quality measures. APA will use the funding to develop and improve quality measures for mental health and substance use disorders, including patient-reported outcomes, patient experience, care coordination, and measures of appropriate use of services. Another goal is to minimize the burden of measurement by eliminating redundancies and low-value quality measures from the QPP. APA will use its PsychPRO registry to test these quality measures. PsychPRO is a CMS Qualified Clinical Data Registry.

“APA is proud to take a leading role in shaping quality measures for our field,” said APA CEO and Medical Director, Saul Levin, M.D., M.P.A. “This grant will help us ensure that patients are receiving the highest standards of psychiatric care and that providers can easily report and be reimbursed for providing high quality services.”

APA is one of seven organizations chosen to receive this three-year award.

(Psychiatrists can learn more about PsychPRO here. The deadline to join the registry to meet the 2018 reporting requirements is October 1.)

Thursday, September 20, 2018

Arthritis Found Highly Prevalent in Older Individuals With Depression

More than half of individuals over age 50 who have depression and more than two-thirds of those with severe depression also have arthritis, according to a report in the International Journal of Geriatric Psychiatry.

“[I]t may be critical for mental health care providers to provide regular arthritis‐related pain assessments and evidence‐based treatments for co‐occurring arthritis in older adults with or at risk for depression,” wrote lead author Jessica Brooks, M.D., a professor of psychiatry at the Geisel School of Medicine and Centers for Health and Aging at Dartmouth College, and colleagues.

The researchers analyzed data from 4,792 men and women over age 50 (average age, 64.5 years) who participated in the National Health and Nutrition Examination Survey. As part of this survey, participants were asked whether they had ever been told by a doctor they had arthritis, and depression symptoms were assessed using the Patient Health Questionnaire.

A total of 2,094 participants (43.7%) reported doctor‐diagnosed arthritis. The prevalence of arthritis increased with the severity of depression: 55.0%, 62.9%, and 67.8% in participants with minor, moderate, and severe depression, respectively. The rate of arthritis was lowest in participants with no depression (38.2%).

The researchers noted that arthritis and disability are known risk factors for depression in older adults. The association between depression and arthritis may be linked to reduced physical activity, as well as to common biological mechanisms that result in inflammation.

“To provide streamlined care and cost‐effective care, future research in geriatric psychiatry is needed to develop and test pilot integrated biopsychosocial strategies and interventions targeting both arthritis and depressive symptoms for delivery by mental health professionals in primary care and specialty care services,” the authors concluded.

For related information, see the chapter on pain in The American Psychiatric Association Publishing Textbook Of Psychosomatic Medicine And Consultation-Liaison Psychiatry, Third Edition and the Psychiatric Services article “Peer-Led Self-Management of General Medical Conditions for Patients With Serious Mental Illnesses: A Randomized Trial.”

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Wednesday, September 19, 2018

Anxiety Linked to Cognitive Decline in Older Adults, Study Shows

Symptoms of anxiety in women appear to be associated with a decline over time in executive function—the ability to plan ahead and organize one’s thoughts, according to a report in The American Journal of Geriatric Psychiatry.

Among both men and women 65 years and older, anxiety appears to predict a decline in verbal memory, which refers to the ability to remember words.

“Adequate treatment of anxiety symptoms could potentially beneficially influence the risk for developing neurodegenerative disease,” wrote Sebastian Köhler, Ph.D., an associate professor of psychiatry at Maastricht University, and colleagues.

Köhler and colleagues analyzed data on 918 participants who were 50 years of age or older in the Maastricht Aging Study, a longitudinal population-based study of factors associated with cognitive aging in the Netherlands.

The researchers measured the anxiety symptoms of the participants at baseline, using the anxiety subscale of the Symptom Check List-90 (SCL-90). The researchers recorded anxiety scores along a continuous scale of severity; they classified patients in the highest quartile as having “high anxiety.” The participants also underwent neuropsychological testing, which measured executive function, memory, speed of information processing, and verbal fluency. During a 12-year follow-up, the cohort was tested every three years.

Overall, being in the highest quartile on anxiety symptoms (“high anxiety”) did not predict a faster decline in executive functioning over time. However, among women, increasing severity of anxiety was associated with a worse cognitive trajectory. A similar sex-specific effect was found for processing speed and verbal fluency.

In contrast, faster decline in verbal memory was associated with “high anxiety” irrespective of sex but was more pronounced in those 65 years and older.

“Further longitudinal research is needed to fully understand the relationship between anxiety and cognition including potentially mediating mechanisms,” the researchers wrote.

For more information, see the Psychiatric News article “Worsening Anxiety in Older Adults May Precede Alzheimer's.”

(Image: iStock/SolStock)

Tuesday, September 18, 2018

Burnout Found to Be Common Among U.S. Resident Physicians

Symptoms of burnout and regret over career choice are common among second-year resident physicians (PGY-2) in the United States, but these symptoms vary according to specialty, reports a study published today in JAMA. Overall, 45% of PGY-2 residents reported symptoms of burnout and 14% reported career choice regret.

“The findings suggest the prevalence of burnout symptoms among resident physicians may be similar to that of practicing physicians (48.8%) and higher than other U.S. workers (28.4% as assessed in 2014 using the same single-item measures adapted from the MBI [Maslach Burnout Inventory]),” wrote Liselotte N. Dyrbye, M.D., M.H.P.E., of the Mayo Clinic and colleagues.

The residents had previously completed questionnaires at the start of medical school and again four years later. In addition to collecting general demographic information, the questionnaire administered during the fourth year of medical school asked participants about anxiety, empathy during clinical encounters, and social support during medical school. The PGY-2 questionnaire asked participants about the frequency of experiencing burnout-related feelings or emotions (“I feel burned out from my work” and “I’ve become more callous toward people since I started this job”) and career choice regret.

Of the 3,574 residents included in the analysis, 1,615 (45.2%) reported at least one symptom of burnout at least weekly. In terms of career and specialty choice regret, 14.1% of the residents reported they would “definitely not” or “probably not” choose to become a physician again, and 7.1% indicated they would “definitely not” or “probably not” choose the same specialty if given the chance to revisit their career and specialty choice.

“Training in the fields of urology, neurology, emergency medicine, or general surgery (relative to internal medicine) and being female were independently associated with a higher RR [relative risk] for reported symptoms of burnout,” Dyrbye and colleagues wrote. “Higher anxiety and lower empathy during year 4 of medical school also were associated with higher RRs for reported symptoms of burnout during residency.”

In a separate article in JAMA, Lisa S. Rotenstein, M.D., M.B.A., of Harvard Medical School and colleagues describe the results of systematic review of studies on the prevalence of burnout in practicing physicians (physicians in training were not included) published before June 1, 2018. Burnout prevalence data, extracted from 182 studies involving 109,628 physicians in 45 countries, were included in the analysis.

The review revealed “remarkable variability in published prevalence estimates of burnout, with estimates of overall burnout ranging from 0% to 80.5%. This wide range reflected the marked heterogeneity in the criteria used to define and measure burnout in the literature, with at least 142 unique definitions for meeting overall burnout or burnout subscale criteria identified,” the authors wrote.

The findings “highlight the importance of developing a consensus definition of burnout and of standardizing measurement tools to assess the effects of chronic occupational stress on physicians,” Rotenstein and colleagues concluded.

To learn more about individual and organizational interventions for burnout, check out APA’s Wellness Toolkit.

(Image: iStock/PeopleImages)

Monday, September 17, 2018

Mental Health Needs of Blacks Are Not Being Met, Says APA President

There is a mental health crisis in the black community, which calls for improved cultural competency training for all psychiatrists as well as more openness among blacks to talk about these issues, said APA President Altha Stewart, M.D. She spoke on Thursday at a session on mental health at the 48th legislative conference of the Congressional Black Caucus Foundation (CBCF), an organization aimed at advancing the global black community by developing leaders, informing policy, and educating the public.

Cultural competency training is aimed at helping health care providers understand patients’ values, beliefs, and behaviors so they can customize treatment to meet patients’ social, cultural, and linguistic needs. For black Americans, this means becoming more aware of the impact of community stressors and how these factors are contributing to their mental health problems, said panelists at the first-ever CBCF panel devoted to mental health in the black community. These factors include violence and trauma, racism, implicit bias, poverty, and limited access to educational, recreational, and employment opportunities, said Stewart, who is also the director of the Center for Health in Justice Involved Youth at the University of Tennessee Health Science Center. “Just being a black person in America can keep you in a constant state of rage,” she said, quoting James Baldwin.

There are only about 2,000 black psychiatrists nationwide, Stewart pointed out. “There are not enough black psychiatrists in America to serve all the black people who need mental health care.” She called for all psychiatrists to become more culturally competent, and for all to encourage young blacks with an interest in STEM (Science, Technology, Engineering, and Mathematics) to enter the mental health field. “Medicine needs their voice. We need their presence.

Patricia Newton, M.D., M.P.H., CEO and medical director of the Black Psychiatrists of America, told attendees that less than half of blacks with mental disorders get the care they need; that number drops to one-quarter when blacks of Caribbean descent are taken into account.

Blacks are also more likely to be subjected to implicit—or unconscious—bias by clinicians, Newton added. “Very often, our people are misdiagnosed.” For example, blacks with depression are often misdiagnosed with schizophrenia and blacks grieving the loss of a loved one, who say they’ve experienced a “visitation,” have been diagnosed as psychotic, due to cultural and religious misunderstandings, she said. Making matters worse, blacks are more likely to be hospitalized for psychosis than to receive community treatment, she said.

Mental illness, suicide, and sexual abuse are seriously underreported among blacks, Stewart said, because these topics are taboo in churches, throughout the community, and even within families. “You can’t get an accurate reporting of what you’re not talking about.”

She encouraged black people to educate themselves about mental illness using reputable sources, openly discuss issues of mental health, and identify people in the community who need help. “We have to dispel the myth that mental illness doesn’t happen to us in the black community, that it’s a ‘white folks’ disease.’ We are suffering in silence and in pain.”

(Image: David Hathcox)

Friday, September 14, 2018

APA Joins Health Organizations in Lawsuit Against Expansion of Short-Term Health Plans

Joining a coalition of seven mental health and health advocacy groups, APA filed suit today in federal court to invalidate a Trump administration rule on short-term, limited duration health plans.

The coalition argued in its complaint that the final rule, issued last month by three federal agencies, violates the plain-English meaning of “short-term” by allowing the sale of the plans for up to 364 days at a time (up from three months) and “limited duration” by allowing renewals for up to three years (up from 12 months). The plans are sold in the individual market to those without employment-based or government-sponsored insurance.

The coalition also argued that the rule is unlawful because it arbitrarily creates an unauthorized “alternative” to Affordable Care Act (ACA)-compliant plans and violates the ACA by undercutting compliant plans and making them increasingly unaffordable. APA was joined in the lawsuit by the National Alliance on Mental Illness, Mental Health America, National Partnership for Women & Families, Association for Community Affiliated Plans, AIDS United, and Little Lobbyists, according to a news release

Short-term health plans may be less expensive than comprehensive plans, but they are not required to cover “essential health benefits,” such as mental health and substance use disorder services, prescription drugs, hospitalization, emergency services, or maternity care. Similarly, short-term plans are not subject to important consumer safeguards or antidiscrimination rules and can deny coverage for any preexisiting condition; set higher premiums based on age, gender, or health status; retroactively cancel coverage; and deny renewals. Short-term plans may also increase uncompensated care for health care providers, the coalition wrote.

“This rule jeopardizes the insurance coverage of many Americans with complex medical needs that require strong, predictable insurance protection and care,” APA President Altha Stewart, M.D., said in a statement. “Without this coverage, patients with complex medical needs will suffer and often end up in emergency rooms, raising health care costs. We call upon the Administration to drop this rule and enforce the protections of the Affordable Care Act.”

For more information, see the Psychiatric News article “Trump Expands Low-Cost, Short-Term Health Plans.”

Thursday, September 13, 2018

Mindfulness Treatment Effective for Veterans With PTSD, Study Finds

Two complementary treatments—mindfulness-based stress reduction (MBSR) and present-centered group therapy (PCGT)—appeared to benefit U.S. military veterans with posttraumatic stress disorder (PTSD), according to a study published today in Psychiatric Research and Clinical Practice.

Complementary and integrative health approaches, such as mindfulness meditation, are intended to be integrated with evidence-based treatment, such as trauma-focused psychotherapy and antidepressant medications, wrote Lori L. Davis, M.D., the associate chief of staff for Research and Development Service at the Veterans Affairs Medical Center in Tuscaloosa, Ala., and colleagues.

Veterans with a diagnosis of PTSD were recruited from three clinical research sites and randomly assigned to receive eight weekly, 90-minute sessions (n=214) of either MBSR or PCGT. Patients were evaluated using the Clinician-Administered PTSD Scale for DSM-IV (CAPS-IV) and the 17-item PTSD Checklist-Self Report at the start of the study as well as at weeks 3, 6, 9, and 16.

MBSR is a technique taught in a series of classes that trains individuals to focus attention on thoughts, sensations, and feelings as they appear. The MBSR group received training in various meditation and stretching techniques, with a focus on mindful awareness, participated in a six-hour retreat, and were given two guided meditation CDs for home use. The PCGT treatment focused on creating an atmosphere of shared support among veterans and helping them to increase their awareness and objectivity of how PTSD affects one’s daily life. The PCGT sessions included discussion of the everyday problems of group members and of how PTSD created or intensified these problems, the authors wrote. Participants in the PCGT group were assigned to keep a journal and had a lunch gathering prior to week 8.

Both the MBSR and PCGT groups achieved significant improvement in PTSD symptoms over time (as measured by their CAPS-IV scores), with no significant differences between groups. Participants in the MBSR group did show a significant improvement in PTSD based on their self-reported PTSD Checklist scores over the nine weeks, compared with the those in the PCGT group; however, this difference was not maintained posttreatment, at week 16.

“The overall small effect sizes of mindfulness-based meditation should be viewed with caution in the context of larger effect sizes of trauma-focused behavioral psychotherapies,” Davis and colleagues concluded. “As with all complementary and integrative health approaches, mindfulness-based meditation should be a supplement to, not a replacement for, trauma-focused behavioral psychotherapies. Additional studies are needed to better understand the effects of MBSR for the treatment of PTSD.”

For related information, see the American Journal of Psychiatry article “Individual Treatment of Posttraumatic Stress Disorder Using Mantram Repetition: A Randomized Clinical Trial.”

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Wednesday, September 12, 2018

Sleep Disorders May Be Missed in Patients With Psychosis

Sleep disorders appear to be common in patients with psychosis, but few appear to be receiving sleep assessments or treatment for such disorders, suggests a report in Schizophrenia Bulletin.

“Taking sleep disorders in psychosis seriously may have important benefits,” Sarah Reeve, D.Phil., of the University of Oxford and colleagues wrote. “Recent manipulation studies have demonstrated that simulating insomnia increases psychotic experiences, and, conversely, treating insomnia reduces psychotic experiences. … [B]y improving sleep it may be possible to improve psychosis, representing an exciting new treatment target.”

For the study, Reeve and colleagues recruited patients aged 18 to 30 who had received a diagnosis of nonaffective psychotic disorder and outpatient clinical services. The researchers used the Diagnostic Interview for Sleep Patterns and Disorders (DISP) and information obtained from sleep diaries and wrist-based activity monitoring devices to assess the presence of sleep disorders in these patients. If the patient met criteria for diagnosis or positive screen for a sleep disorder, they were then asked whether they had ever discussed the issue with a medical professional and whether they received treatment for the disorder.

Of the 60 patients included in the study, 48 (80%) received a positive screen or diagnosis for at least one sleep disorder. The most common sleep diagnoses were insomnia (n=30, 50%) and nightmare disorder (n=29, 48.3%), but as the authors noted, “there was a broad range of sleep issues presenting in this group and comorbidity was high, with an average of 3.3 sleep disorders per patient.”

Patients with at least one sleep disorder reported more severe paranoia, hallucinations, depression, and anxiety compared with those who did not report a sleep disorder (as assessed by Specific Psychotic Experiences Questionnaire and Depression Anxiety and Stress Scale). The researchers found that over half of the sleep disorders had been discussed with a clinician but almost three-quarters had received no treatment.

“Diagnostic systems such as DSM-5 recommend that sleep problems should be assessed and treated irrespective of other psychiatric comorbidities. This does not appear to be happening in psychosis services,” Reeve and colleagues wrote. “[I]ndependent of any relationship with psychotic experiences, our view is that the assessment and treatment of sleep disorders among those with psychosis merits greater clinical attention.”

For related information, see the Psychiatric News article “Brains of People With Insomnia Stay More Active During Sleep.”

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Tuesday, September 11, 2018

Intervention Found to Slow Cognitive Decline in Older Blacks With MCI

Encouraging older black adults with mild cognitive impairment (MCI) to set goals and develop plans to increase cognitive, physical, and/or social activities may help to slow cognitive decline, according to a study published Monday in JAMA Neurology.

MCI is known to increase the risk of progressive cognitive decline. While some observational studies have suggested that engaging in cognitive, physical, and/or social activity may prevent cognitive decline, “these studies have included few black individuals who may differ from white individuals in risk profile (e.g., cognitive reserve, hypertension, diabetes), mechanisms of decline (i.e., microvascular disease, amyloid deposition), and rates of dementia (i.e., black individuals have almost twice the rate),” wrote Barry W. Rovner, M.D., of Thomas Jefferson University in Philadelphia and colleagues.

For the current study, Rovner and colleagues recruited adults who sought memory screening at senior centers, senior housing sites, churches, and primary care clinics in Philadelphia. Adults aged 65 and older who self-identified as black and had amnestic MCI (according to the National Institute on Aging and Alzheimer’s Association criteria) were included in the trial. The researchers excluded individuals who had other psychiatric disorders, were taking antidementia medication, and/or had severe sensory deficits.

The researchers randomly assigned 221 adults to behavioral activation (encouraged patients to set goals and action plans to increase cognitive, physical, and/or social activity) or supportive therapy (welcomed patients into structured discussion about the experience of aging, memory loss, and social isolation but did not include any of behavioral activation’s goal-setting strategies). Both groups received five in-home, 60-minute treatment sessions over four months and six in-home, 60-minute follow-up maintenance sessions over the next 20 months.

A total of 77 people in the behavioral activation group and 87 people in the supportive therapy group completed the two-year study. Over the course of the study, behavioral activation participants engaged in significantly more cognitive activities at 6, 12, 18, and 24 months than did supportive therapy participants; however, there were no differences in physical or social activity, the authors reported.

The two-year incidence of memory decline (as assessed by the total recall score of the Hopkins Verbal Learning Test–Revised at 6, 12, 18, and 24 months) was 1.2% for behavioral activation versus 9.3% for supportive therapy. People in the behavioral activation group also had stable function scores (as assessed by University of California Performance-Based Skills Assessment) over time, whereas function in participants in the supportive therapy group declined.

“To our knowledge, this is the first RCT [randomized, controlled trial] to demonstrate that behavioral activation specifically prevents cognitive and functional decline in older black individuals with MCI,” the authors wrote. “No effective pharmacotherapy exists to prevent cognitive decline in persons with MCI, and black individuals are twice as likely to decline cognitively, meet criteria for MCI, and develop dementia as white individuals. … These facts highlight the need for culturally competent preventive treatments such as behavioral activation to reduce the burden of dementia and achieve health equity for everyone.”

For related information, see the Psychiatric News article “Psychiatrists Write MH Resource for Black Community.”

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Friday, September 7, 2018

Guidelines for Treating Perimenopausal Depression Released

Studies suggest women are at an increased risk of depression during perimenopause—the time right before menopause when female hormones start to decline. A multi-institute expert panel convened by the North American Menopause Society and the National Network on Depression Centers Women and Mood Disorders Task Group has now developed and published the first-ever guidelines for the evaluation and treatment of perimenopausal depression.

The guidelines were jointly published in the journals Menopause and the Journal of Women's Health.

“The notion of a menopause-associated depression … has been the focus of clinical and scientific debate for years,” wrote the panel members. “The lack of consensus on this issue has also led to a lack of clarity [on] how to evaluate and treat depression in women during the menopausal transition and postmenopausal period.”

The expert panel, co-chaired by Pauline Maki, Ph.D., of the University of Illinois at Chicago College of Medicine and Susan Kornstein, M.D., of Virginia Commonwealth University focused on five areas: epidemiology, clinical presentation, effects of antidepressants, effects of hormone therapy, and efficacy of other therapies such as psychotherapy and exercise.

The recommendations made by the panel include the following:

  • Proven therapeutic options for depression such as antidepressants and psychotherapy are best for treating major depressive episodes during perimenopause.
  • Existing data suggest that antidepressants can be given to perimenopausal women at doses typically prescribed to adults.
  • There is some evidence that estrogen therapy has antidepressant effects when administered to perimenopausal women with depression. However, estrogen therapy has been shown to be ineffective as a treatment for depressive disorders in postmenopausal women.
  • Hormonal contraceptives may improve depressive symptoms in women approaching menopause.

To read more about depression and menopause, see the Psychiatric News article “Older Age at Menopause May Reduce Risk of Depression.”

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Thursday, September 6, 2018

Occupational Injury Raises Long-Term Suicidality Risk, Study Finds

Occupational injury, particularly an injury which leaves workers severely harmed or results in work instability, may increase the long-term risk of suicidality, according to study in the Journal of Clinical Psychiatry.

For the study, Wei-Shan Chin, Ph.D., a postdoctoral research fellow at the National Institute of Environmental Health Sciences in Taiwan, and colleagues recruited workers from Taiwan who sustained occupational injuries requiring hospitalization for three days or longer. Some 2,300 workers responded to questionnaires sent by mail at three months and 12 months after the injury; the questionnaires collected information on the workers’ demographics, work instability, injury severity, psychological symptoms (Brief Symptom Rating Scale [BSRS-5] and the Posttraumatic Symptom Checklist [PTSC]), and suicidal ideation. Workers with a high score on the BSRS-5 or PTSC were asked to take an in-depth psychiatric evaluation administered by psychiatrists or trained nurses who used a structured clinical interview (a Chinese version of the Mini-International Neuropsychiatric Interview [MINI]). Six years later, 1,715 of these workers completed a similar assessment.

The estimated MINI-diagnosed suicidality rates were 5.4%, 4.8%, and 9.5% at three months, 12 months, and six years after occupational injury, respectively, the authors reported. At six years, participants with an injury that had a major negative impact on their physical appearance had a 1.7 times greater risk of suicidal ideation; those with unstable employment had a 1.5 times greater risk; and those with reduced income within the past year compared with before the injury had a 1.6 higher risk.

“These results suggest that suicidality does not improve with time but remains a vital issue after occupational injury,” the authors wrote. Thus, periodic monitoring of psychological and physical health is warranted after an occupational injury. Moreover, the authors noted, “Future studies should develop effective strategies for minimizing suicidality after occupational injury and for the early detection of high-risk workers.”

For related information, see the Psychiatric News article “Data Mining May Help Identify Suicide Risk.”

Wednesday, September 5, 2018

Parents of Schizophrenia Patients Found More Likely to Seek Psychiatric Care

The demands of providing long-term care to a family member with severe, chronic illness have been shown to have a negative effect on the health of caregivers. A study published Monday in Schizophrenia Bulletin now suggests that parents of patients with schizophrenia are more likely to seek care for mental illness than parents of patients with other chronic diseases and healthy controls.

Ellenor Mittendorfer-Rutz, Ph.D., of Karolinska Institutet and colleagues analyzed data derived from Swedish nationwide registers to compare health care resource use, adverse health status, and more of 18,215 parents of patients with schizophrenia, 11,292 parents of patients with multiple sclerosis, 15,516 parents of patients with rheumatoid arthritis, 34,715 parents of patients with epilepsy, and 18,408 parents of healthy controls without a chronic illness. (Previous studies show multiple sclerosis, rheumatoid arthritis, and epilepsy place a high burden on caregivers.) The investigators assessed trends for each of the designated outcomes from four years before the child was diagnosed with the chronic illness to seven years after this diagnosis was made.

“Use of specialized health care due to psychiatric or somatic diagnoses showed an increasing trend for all parents throughout the observation period,” Mittendorfer-Rutz and colleagues wrote. Parents of patients with schizophrenia had a higher risk of psychiatric health care use compared with the other parental groups during follow-up, they reported.

The most frequent diagnostic groups of psychiatric diagnoses among the parents were affective and anxiety disorders as well as schizophrenia, they noted. Parents of children with moderately severe schizophrenia had a slightly higher risk of use of psychiatric services compared with parents of children with less severe schizophrenia.

“Different psychosocial interventions aim[ed] at parents of patients with schizophrenia have been reported to be helpful to reduce stress, which may also play a role in stabilizing mental health of such parents,” the researchers wrote. “Unfortunately, no data were available for this study regarding the proportion of parents attending such intervention.”

For related information, see the Psychiatric Services article “Psychological Distress Among Caregivers of Individuals With a Diagnosis of Schizophrenia or Schizoaffective Disorder.”

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Tuesday, September 4, 2018

Physician Burnout Poses Risks to Patient Safety

Burnout can have profound physical and emotional consequences on physicians. A large meta-analysis published today in JAMA Internal Medicine now clarifies the adverse effects of physician burnout on patient care. The meta-analysis found that physicians with burnout are twice as likely to be involved in patient safety incidents, more than twice as likely to deliver suboptimal care due to low professionalism, and more than twice as likely to receive low satisfaction ratings from patients.

“We found that physician burnout is associated with a reduced efficiency of health care systems to deliver high quality, safe care to patients,” wrote Maria Panagioti, Ph.D., of the University of Manchester, United Kingdom, and colleagues. “Preventable adverse events cost several billions of dollars to health care systems every year. Physician burnout therefore is costly for health care organizations and undermines a fundamental societal need for the receipt of safe care.”

Panagioti and colleagues combined data from 47 separate studies that encompassed 42,473 physicians. The combined analysis showed that physician burnout was associated with a 1.96-fold increased risk of patient safety incidents (such as adverse events due to giving improper medications), 2.31-fold increased risk of poor quality of care due to low professionalism (such as failing to make proper referrals), and 2.28-fold increased risk of reduced patient satisfaction reports. Emotional exhaustion, depersonalization, and a lower sense of personal accomplishment all contributed to these adverse patient outcomes, though depersonalization showed the most adverse association with the quality and safety of patient care and with patient satisfaction.

The authors also found that the association between burnout and low professionalism was particularly strong in residents and early-career (≤5 years post residency) physicians compared with middle- and late-career physicians.

“It is likely that burnout signs among residents and early-career physicians have detrimental associations with their work satisfaction, professional values, and integrity,” Panagioti and colleagues wrote. “Health care organizations have a duty to support physicians in the demanding transition from training to professional life. Residents will be responsible for the health care delivery for over two decades in the future. Investments in their wellness and professional values, which are largely shaped during early-career years, are perhaps the most efficient strategy for building organizational immunity against workforce shortages and patient harm/mistrust.”

To learn more about individual and organizational interventions for burnout, check out APA’s Wellness Toolkit.

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Friday, August 31, 2018

Prazosin May Reduce Heavy Drinking in Patients With Alcohol Use Disorder

Prazosin—an α-1 adrenergic receptor antagonist—may be able to help people with alcohol use disorder reduce heavy drinking over time, according to a study published this week in the AJP in Advance.

“This study supports the growing body of work suggesting that α-1 noradrenergic antagonists that cross the blood-brain barrier may help people limit unsafe heavy drinking,” wrote Tracy L. Simpson, Ph.D., of the VA Puget Sound Health Care System and colleagues.

Simpson and colleagues previously conducted a pilot study of 24 adults with alcohol dependence treated with prazosin for six weeks; the study found that those treated with prazosin reported fewer drinking days toward the end of the six-week trial than those treated with placebo. For the current study, the researchers assigned 92 participants with alcohol use disorder to receive prazosin or placebo in a 12-week double-blind study.

The study participants attended twice-weekly study visits during weeks 1 and 2—as prazosin was titrated (target dosing of 4 mg in the morning, 4 mg in the afternoon, and 8 mg at bedtime)—and then weekly study visits weeks 3 through 12. During the study visits, the researchers collected urine (to measure medication adherence), checked patient vitals such as blood pressure, and assessed the medication’s effects. Additionally, participants were asked to complete 4- to 5-minute interactive voice response calls daily to report the previous day’s drinking, cravings, and study medication doses consumed.

Analysis of data from the 80 participants who completed the two-week titration phase revealed that days of heavy drinking (≥4 drinks for women, ≥5 drinks for men) decreased more rapidly from week 3 to week 12 in the prazosin group than in the placebo group. Similarly, from week 3 to week 12, the prazosin group reduced the number of drinks per week by 8.0, compared with 1.5 for the placebo group. In contrast, at week 12 there was no difference between the two groups in the total number of drinking days or in craving changes over time, the authors noted. Participants in the prazosin condition were more likely to report drowsiness and edema than participants in the placebo condition.

“These results indicate that prazosin has the potential to reduce the likelihood of heavy drinking and number of drinks per week over time but not the number of drinking days per week,” Simpson and colleagues wrote. “[P]razosin may be most useful in reducing heavy drinking associated with negative consequences, which is consistent with a harm reduction approach characterized by safer consumption rather than full abstinence.”

For related information, see the Psychiatric News article “Varenicline May Lower Heavy Drinking, Smoking In Men With AUD.”

(Image: iStock/Savushkin)

Thursday, August 30, 2018

Soldiers Who Attempt Suicide Often Have No Prior Mental Health Diagnosis

More than one-third of enlisted U.S. soldiers who attempted suicide (36%) had no previous mental health diagnosis, according to an study published yesterday in JAMA Psychiatry.

“It is likely such soldiers had undetected mental disorders,” wrote Robert J. Ursano, M.D., director of the Center for the Study of Traumatic Stress at the Uniformed Services University of the Health Sciences, and colleagues. Many factors may contribute to mental health problems going undiagnosed, including soldiers not perceiving a need for treatment or seeking help, they wrote.

Ursano and colleagues studied administrative data from the Army Study to Assess Risk and Resilience in Servicemembers (Army STARRS), including records of 9,650 enlisted Army soldiers who had attempted suicide to pinpoint risk factors among those without a previous mental health diagnosis. The authors examined event report records, as well as army personnel, medical, legal, and family services records for soldiers who attempted suicide and compared them with soldiers with no history of suicidality or death.

More than 3,500 soldiers with a documented suicide attempt did not have a previous mental health diagnosis. Among these soldiers, those in the first year of service were most likely to attempt suicide (odds ratio [OR]=6). Among the other variables examined, suicide risk was also highest among soldiers with physical health care issues: inpatient hospitalizations (OR=3.8), eight or more outpatient visits in the past two months (OR=3.3), or past-month injury related outpatient care (OR=3.0). Soldiers with family violence, too, were 2.9 times more likely to attempt suicide.

Other significant risk factors for suicide attempt among soldiers with no prior mental health diagnosis included female sex (OR=2.6), previous deployment (OR=2.4), major violent crime perpetration (OR=2.0), or less than high school education (OR=1.9).

Most of these risk factors were also associated with suicide attempts among soldiers with a previous mental health diagnosis, although the strength of the associations differed. In both groups—soldiers with and without a history of mental health diagnosis—the odds of suicide attempt were higher among soldiers who were female, younger, non-Hispanic white, less educated, in their first four years of service, not currently deployed, with a delayed promotion or demotion, or an occupation of combat medic or combat arms.

“Interactions with medical, legal, and family services systems create assessment and prevention opportunities for soldiers with previously undetected suicide attempt risk,” the authors wrote. “Ensuring routine assessment of psychological distress and suicide risk during all encounters can help identify at-risk soldiers who are unknown to the mental health care system.”

For related information, see the Psychiatric News article “STARRS Findings Shed More Light on Army Suicides.”

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Wednesday, August 29, 2018

Ketamine's Antidepressant Effects Appear to Depend on Opioid System, Study Shows

The antidepressant effects of ketamine appear to depend on activation of the brain’s opioid receptors, underscoring the drug’s addictive potential, according to a report published today in AJP in Advance.

The study, by Alan Schatzberg, M.D. (pictured left), the Kenneth T. Norris Jr. Professor of Psychiatry and Behavioral Sciences at Stanford University School of Medicine, and colleagues, found that when patients with treatment-resistant depression were treated with the opioid antagonist naltrexone before receiving an infusion of ketamine, the antidepressant effects of ketamine were dramatically diminished.

“While opioids have a history of use as antidepressants, they pose a significant risk if used chronically,” Schatzberg and colleagues wrote. “Thus, the abuse and dependence potential of frequent ketamine treatment in major depression needs further study, and our results provide strong justification for further caution against widespread and repeated use of ketamine before further mechanistic testing has been performed.”

The researchers originally planned a crossover trial of 30 adults with treatment-resistant depression comparing a 0.5 mg/kg intravenous infusion of ketamine preceded by either oral placebo or oral naltrexone (50 mg). All participants were required to have a score of at least 20 on the 17-item Hamilton Depression Rating Scale (HAM-D). Each participant was also required not to have benefited sufficiently from trials of at least four antidepressant medications or other somatic treatments (such as electroconvulsive therapy, vagus nerve stimulation, or deep brain stimulation).

An initial 12 patients completed both arms of the crossover trial. In the ketamine plus placebo condition, seven of the 12 patients met the criterion for response (defined as a reduction of 50 percent from baseline to post-infusion day 1 in 17-item HAM-D score); five of the seven responders met criteria for remission (defined as a score of 7 or less on HAM-D). In contrast, none of the patients who responded to ketamine plus placebo met the criteria for response the day after receiving ketamine plus naltrexone.

Patients receiving ketamine plus placebo experienced a dramatic reduction in mean 17-item HAM-D, with an average reduction of 22.3. There was also a statistically significant reduction from baseline in the ketamine plus naltrexone condition, but that improvement was significantly lower, with an average reduction of 5.6. Because patients who took naltrexone before ketamine continued to experience the dissociative effects of ketamine without the robust antidepressant response seen in the placebo group, the investigators halted the trial without recruiting more patients.

“With these new findings, we should be cautious about widespread and repeated use of ketamine before further mechanistic testing has been performed to determine whether ketamine is merely another opioid in a novel form,” Mark George, M.D., a professor of psychiatry, radiology, and neuroscience and director of the Brain Stimulation Laboratory at the Medical University of South Carolina, wrote in an accompanying editorial. “[W]e need to better understand ketamine’s mode of action and how it should best be used and administered.”

A detailed report of this study will appear in a future issue of Psychiatric News and its enewsletter PsychoPharm. For related information, see the Psychiatric News article “ ‘Cautious Optimism’ Marks Outlook for Ketamine, Mood Disorders.”

Tuesday, August 28, 2018

Engagement in Family Psychoeducation for FEP May Vary by Race, Ethnicity

While connecting individuals with first-episode psychosis (FEP) to coordinated specialty care is known to benefit patients, a report published today in Psychiatric Services in Advance suggests that patients who are members of racial/ethnic minority groups may be less likely to receive a key component of this care.

Oladunni Oluwoye, Ph.D., of Washington State University and colleagues conducted a secondary data analysis of the Recovery After an Initial Schizophrenia Episode, Early Treatment Program (RAISE-ETP) data set. The study included 181 patients with schizophrenia and related disorders who received usual community care and 223 who received coordinated specialty care called NAVIGATE. NAVIGATE includes four core interventions: personalized medication management, family psychoeducation, resilience-focused individual therapy, and supported employment and education.

As part of the RAISE-ETP study, patients were assessed at baseline and at months 6, 12, 18, and 24 using the Positive and Negative Syndrome Scale (PANSS) total score and scores on five PANSS subscales (negative symptoms, positive symptoms, uncontrolled hostility, disorganized thoughts, and anxiety and depression). Also, the participants were asked to assess their use of services, such as medication management, family psychoeducation, and individual therapy monthly over the 24-month treatment period.

Among those in the community care group, “non-Hispanic blacks scored significantly higher throughout treatment on measures of positive symptoms, disorganized thoughts, and uncontrolled hostility compared with non-Hispanic whites, and non-Hispanic blacks were less likely than non-Hispanic whites to receive individual therapy,” Oluwoye and colleauges wrote. “Families of Hispanic participants in usual community care were less likely than non-Hispanic white families to receive family psychoeducation.”

Race and ethnicity were not associated with differences in psychiatric symptoms over time in the NAVIGATE group; however, “among NAVIGATE participants, non-Hispanic blacks and those in the group categorized as other were less likely than non-Hispanic whites to engage in family psychoeducation during the 24-month treatment period,” the authors reported. “These findings suggest that family psychoeducation may not appeal, may not be consistently offered, or may not be appropriately tailored [to] non-Hispanic blacks and other racial and ethnic minority groups.”

Oluwoye and colleagues concluded, “[O]ur secondary data analyses highlight the effectiveness of NAVIGATE, compared with usual community care, as a coordinated specialty care program for improving functioning and symptoms for individuals from racial-ethnic minority groups experiencing FEP. However, the findings also highlight racial-ethnic disparities in the NAVIGATE condition in participation in family psychoeducation, resulting in lower rates of family engagement among non-Hispanic blacks and individuals from other racial and ethnic minority groups.”

For related information, see the Psychiatric News article “Social Therapy Improves Engagement in Early Psychosis Treatment.”

(Image: iStock/PeopleImages)

Monday, August 27, 2018

Prenatal Maternal Depression, Anxiety May Alter Early Brain Development

Depression and anxiety during the third trimester of pregnancy may affect early brain development, reports a study published today in JAMA Pediatrics. The study suggests that the intensity of maternal depressive and/or anxious symptoms influences the density of the infants’ white matter—bundles of nerve fibers that connect various brain regions.

“Maternal depression and anxiety are known to adversely affect child behavioral and emotional outcomes,” wrote Douglas Dean III, Ph.D., of the University of Wisconsin-Madison and colleagues. “[O]ur findings show that neural pathways may differ in these children as well.”

Dean and colleagues enrolled 149 mother-infant pairs for this neuroimaging study. The pairs were part of an ongoing clinical study examining the association between early-life experience and infant brain development. As part of this study, the mothers completed depression and anxiety questionnaires at weeks 28 and 35 of pregnancy. The investigators later took MRI scans of sleeping infants at age one month. Not all infants slept through the entire scan, so the final analysis included 101 infants (53 male, 48 female).

The investigators found a sex-specific connection between the mother’s depression and anxiety scores and infants’ white matter composition. In female infants, higher maternal depression/anxiety scores were associated with lower white matter density (which reflects fewer, less tightly packed nerve fibers) in frontal brain regions. In boys, however, higher symptom scores were associated with higher white matter density in these regions.

“Such associations may be linked to differing time courses of white matter development, with white matter in females developing earlier than in males,” Dean and colleagues wrote. “These findings do not imply that white matter in males is resilient to prenatal maternal symptoms; instead, they suggest the possibility that such microstructural alterations in males may be detected at a different time during development.”

They added, “Because of the rapid postnatal maturation of white matter and the likelihood that prenatal and postnatal influences within the first month contribute to shaping brain connectivity, it is likely that any developmental outcome that we study is the joint product of prenatal and postnatal influences.”

For related information, see the Psychiatric News article “Maternal Mental Health: Moving Mental Health Care Upstream,” by Amritha Bhat, M.D., M.P.H.

(Image: iStock/Halfpoint)

Friday, August 24, 2018

Lower White Matter Density at Age 14 May Signal Future Depression

Adolescents with a lower density of white matter—the nerve fibers that connect different brain regions—are at higher risk of developing depression, according to a report in AJP in Advance.

Previous research has shown that adolescents with depression have reduced white matter density. This new study shows that these structural changes predate the onset of depression, suggesting they may represent a biomarker of depression vulnerability.

Researchers with Europe’s IMAGEN Consortium took brain scans of 96 14-year-olds with subthreshold depression and 336 age-matched healthy controls. The participants were categorized as having subthreshold depression if they had experienced at least three depressive symptoms, including at least one core symptom (abnormally depressed, irritable mood, or loss of interest) in the past four weeks, without fulfilling criteria for a DSM-IV major depressive episode. The adolescents then had a follow-up assessment at age 16 to screen for depression and other psychiatric disorders (no brain scans were taken during follow-up).

The investigators used a technique called fractional anisotropy to measure the density of nerve fibers in the brains of the adolescents. They found that on average those with subthreshold depression at age 14 had lower fiber density, particularly in two regions: the corpus callosum (the band of nerves that joins the two hemispheres of the brain) and the nerve fibers that connect the corpus callosum to the anterior cingulate cortex (a brain region that mediates behaviors such as attention and reward anticipation).

This reduced nerve fiber density was more pronounced in the adolescents who developed depression by 16. The researchers developed an algorithm that identified adolescents who developed depression with about 75% accuracy.

Previous studies have suggested that white matter changes may be associated with other psychiatric disorders in adolescents, including generalized anxiety disorder and attention-deficit/hyperactivity disorder, the authors wrote. According to their analysis, reduced nerve fiber density “did not predict higher risk for any diagnosis other than depression at follow-up,” the authors noted.

They confirmed the association between reduced nerve fiber density and depression risk in an independent set of 686 adolescent brain scans (all from adolescents without psychiatric disorders at baseline) that were part of the IMAGEN database. “[O]ur imaging findings appear to be specific to increased risk for depression,” they wrote.

For more information on depression in adolescents, see the Psychiatric News article “Brains of Teen Girls Resilient to Depression Differ From Brains of Others.”

(Image: iStock/wenht)

Thursday, August 23, 2018

Adjunctive Aripiprazole May Reduce Prolactin-Related Side Effects of Antipsychotics in Women

Adjunctive aripiprazole appears to effectively treat prolactin-related side effects of antipsychotic treatment in women, according to a report in the August issue of the Journal of Clinical Psychopharmacology.

Antipsychotic treatment in women can result in hyperprolactinemia—a condition of elevated prolactin in the bloodstream that may cause irregular menstrual periods or no menstrual periods (amenorrhea), milky discharge from the breasts (galactorrhea) when not pregnant or breast-feeding, and/or painful intercourse due to vaginal dryness.

Deanna Kelly, Pharm.D., director of the Treatment Research Program at Maryland Psychiatric Research Center, and colleagues randomized 46 premenopausal women with a diagnosis of schizophrenia, schizoaffective disorder, or bipolar disorder who were stable on antipsychotics to 16 weeks of placebo or adjunctive aripiprazole (starting with 5 mg/day for the first two weeks and escalating doses to 15 mg/day if symptoms didn’t resolve). All women in the trial had elevated prolactin levels of greater than 24 ng/mL and reported menstrual dysfunction, galactorrhea, and/or sexual dysfunction related to use of an antipsychotic. At baseline, 70% of the women had at least two of these side effects.

The study participants were evaluated every two weeks for measurement of morning prolactin levels, breast exams, menstrual diary review, and a review of side effects, including sexual function.

Improvements were seen on all prolactin-related side effects for women taking adjunctive aripiprazole compared with women taking placebo. Aripiprazole was particularly effective at improving galactorrhea, with almost 80% of women having resolution of this side effect at the end of the 16 weeks compared with 33% in the placebo group.

Women also responded favorably to questions related to resumption of their menstrual periods and improvements in sexual function and libido. Women in the study indicated at exit interview that the resolution of prolactin-related symptoms would make them more inclined to continue taking their antipsychotic medication.

Psychiatric News first reported on the results of the Dopamine Partial Agonist Aripiprazole for the Management of Symptomatic Elevated Prolactin (DAAMSEL) trial after a presentation by Kelly at the 2017 meeting of the International Congress on Schizophrenia Research.

At the time, Kelly said the addition of aripiprazole to an antipsychotic regimen should be regarded as an example of “rational polypharmacy” that can help treatment adherence. “These are improvements that do really matter to women and may help with recovery-oriented treatment,” she said.

For related information, see Managing the Side Effects of Psychotropic Medications, Second Edition, from APA Publishing.

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